Principles & Concepts
Part - I
Dr. D. N. Bid
The Sarvajanik College of Physiotherapy,
Rampura, Surat – 395003.
• To complete a musculoskeletal assessment of a
patient, a proper and thorough systematic
examination is required.
• A correct diagnosis depends on a knowledge of
functional anatomy, an accurate patient history,
diligent observation, and a thorough
• The differential diagnosis process involves the
• clinical signs and symptoms,
• physical examination,
• knowledge of pathology and mechanisms of
• provocative and palpation (motion) tests, and
• laboratory and diagnostic imaging techniques.
• The purpose of the assessment should be to fully
and clearly understand the patient's problems,
from the patient's perspective as well as the
clinician's, and the physical basis for the
symptoms that have caused the patient to
• As James Cyriax stated,
"Diagnosis is only a matter of applying
one's anatomy." 4
• One of the more common assessment recording
Methods used is the problem- oriented medical records
method, which uses "SOAP" notes.
• SOAP stands for the four parts of the assessment:
• Assessment, and
• Regardless of which system is selected for assessment,
the examiner should establish a sequential method to
ensure that nothing is overlooked.
• The assessment must be organized, comprehensive, and
• In general, the examiner compares one side of the body,
which is assumed to be normal, with the other side of
the body, which is abnormal or injured.
• Often, the examiner can make the diagnosis by
simply listening to the patient.
• Even if the diagnosis is obvious, the history
provides valuable information about the
disorder, its present state, its prognosis, and the
• The history also enables the examiner to determine the
type of person the patient is, any treatment the patient has
received, and the behavior of the injury.
• In addition to the history of the present illness or injury,
relevant past history, treatment, and results should be
• Past medical history should include any major illnesses,
surgery, accidents, or allergies.
• In some cases, it may be necessary to delve into
the social and family histories of the patient if
they appear relevant.
• Lifestyle habit patterns, including sleep patterns,
stress; workload, and recreational pursuits,
should also be noted.
• It is important that the examiner keep the
patient focused and discourage irrelevant
information; this should be done politely but
• In addition, the examiner should listen for any
potential "red flag" signs and symptoms (Table
1-1) that would indicate the problem is not a
musculoskeletal one and that the problem
should be referred to the appropriate health
• The history is usually taken in an orderly
• It offers the patient an opportunity to describe
the problem and the limitations caused by the
problem as he or she perceives them.
• In any musculoskeletal assessment, the examiner
should seek answers to the following pertinent
• 1. What is the patient's age?
• Certain diseases happen at particular age.
• Perthes dz
• OA, Osteoporosis
• 2. What is the patient's occupation?
• Laborer : muscle strain
• Office worker : ’’
• 3. Why has the patient come for help?
• History of present illness or chief complaint
• 4. Was there any inciting trauma (macro-
trauma) or repetitive activity (micro-trauma)?
• Mechanism of injury,
• Predisposing factors 17
• 5. Was the onset of the problem slow or
• 6. Where are the symptoms that bother the
• Symptoms are localized or generalised
• 7. Where was the pain or other symptoms
when the Patient first had the complaint?
• Pain intensity
• Trigger points
• Peripheralization, centralization,
• Referred pain
• 9. How long has the problem existed? What are the duration
and frequency of the symptoms?
• ? the condition is acute, subacute, chronic, or acute on chronic.
• Acute 7-10 days
• Sub-acute 10 days to 7 weeks
• Chronic - > 7 weeks
• 10. Has the condition occurred before?
• If so, what was the onset like the first time?
• Where was the site of the original condition, and has there
been any radiation (spread) of the symptoms?
• If the patient is feeling better, how long did the recovery take?
• Did any treatment help to relieve symptoms?
• Does the current problem appear to be the same as the
previous problem, or is it different?
• If it is different, how is it different?
• Answers to these questions, determine the location and severity of the injury.
• 11. Are the intensity, duration, and/or frequency of pain
or other symptoms increasing?
• Getting worse
• Use of pain questionnaire or scales..
• 12. Is the pain constant, periodic, episodic
(occurring with certain activities), or
• Constant pain: chemical irritation, tumors, visceral lesions…
• Periodic pain: mechanical or movement related and stress…
• Episodic pain: specific activities …………..
• 13. Is the pain associated with rest?
Activity? Certain postures? Visceral
function? Time of day?
• 14. What type or quality of pain is exhibited?
• Nerve pain, Bone pain,
• Vascular pain, Muscle pain,
• Neuropathic pain, Somatic pain
• 15. What types of sensations does the patient feel, and
where are there abnormal sensations?
• 16. Does a joint exhibit locking, unlocking,
twinges, instability, or giving way?
• Locking, Pseudolocking, Spasm locking….
• Giving way…
• Translational instability
• Anatomical instability
• Functional instability..
• Voluntary instability & involuntary instability.. ..
• Circle concept of instability……………….
• 17. Has the patient experienced any bilateral
spinal cord symptoms, fainting, or drop attacks?
• Severe neurological problems
• 18.Are there any changes in color of the limb?
• ? Circulatory problems/ RSD/ Raynaud’s dz
• 19. Has the patient been experiencing any life
or economic stresses?
• ? Psychological stress 35
• 20. Does the patient have any chronic or serious
systemic illnesses that may influence the course
of the pathology or the treatment?
• 21. Is there any thing in the family history that
may be related, such as tumors, arthritis, heart
disease, diabetes, and allergies?
Some disease processes and pathologies have a familial incidence.
• 22. Has the patient undergone an x-ray
examination or other imaging techniques?
• 23. Has the patient been receiving analgesic,
steroid, or any other medication?
• 24. Does the patient have a history of surgery?
• If so, when was the surgery performed, what was the
site of operation, and what condition was being
• Sometimes, the condition the examiner is asked to treat
is the result of the surgery.
• Has the patient ever been hospitalized? If so, why?
• It is evident that the taking of an accurate, detailed history is
•Listen to the patient- he or she is
telling you what is wrong!
• With experience, the examiner is often able to make a
preliminary "working“ diagnosis from the history alone.
• The observation and examination phases of the assessment
are then used to confirm, alter, or refute the possible